Social phobia syndrome in Japan

Social Phobia Syndrome in Japan Tooru Takahashi Recently,

social phobia has been described

(ICD)- 10 (1986 1920s.

Draft),

Japanese

as a diagnostic

psychiatrists

have paid particular

have not yet given explicit behavioral important features

facets

diagnostic

of this phobic symptom

manifested

in embodied

social phobia syndrome

in DSM-III

complex,

has not been considered

or ICD-10.

D 1989

by Grune & Stratton, Inc.

Classification

of Diseases

under the anxiety disorders.

attention

to these phobic states.

Since the

Though,

criteria to social phobia, they have elucidated

communications

DSM-III

and in International

entity and classified

especially

those of obsessional

of the patient

they many

and delusional

with this phobia. Thus, in Japan,

as a mere phobic anxiety

disorder

described

in

I

T WAS ONLY RECENTLY that social phobia, a psychiatric syndrome neglected for a long time, achieved a diagnostic label in widely used classifications of mental disorders. Thus, DSM, in its third edition published in 1980, and International Classification of Diseases (ICD), in its draft of 1986 for the tenth revision, describe, for the first time, social phobia as a distinct clinical condition. They classify this syndrome under the rubric of anxiety disorders. The term “phobia” has, however, suffered from a plethora of classification labels. For example, agoraphobia is, sometimes, classified as a kind of anxiety disorder, while mysophobia is, in most cases, treated as an obsessive-compulsive disorder. The term “phobia” does not simply mean an excessive fear. It means a “morbid” fear. The morbidity of phobic fears manifests itself in pathological anxieties as well as obsessional and delusional psychopathologies. Social phobia syndrome, as described in this report, has more or less obsessional and delusional properties. Therefore, it does not completely fit with the DSM or ICD characterization of “social phobia.” In the 192Os, Morita, a Japanese psychiatrist, described clinical features of social phobia and later named it tai-jin k~O~u. KyOjii means fears, while tai-jin means social contacts where the exchange of words and glances takes place between individuals in each other’s presence. Morita and many other Japanese psychiatrists have paid particular attention to tai-jin kyOfu and have elaborated the clinical conception of this symptom complex. Social phobia syndrome in this report consists of this tai-jin kybjii symptoms. HISTORICAL

REMARKS

The term phobies sociales was first used by Janet in his monograph on to group a wide variety of morbid fears arising from social contacts, such as an intense fear of blushing in the presence of others, or a persisting fear of trivial or imaginary physical deformities being noticed. Janet pointed out that “the

psychasthtnie’

From the Division of Adult Mental Health. National Insiitute of Mental Health, Ichikawa, Chiba. Japan. tDeceased. Address reprint requests to Tooru Takahashi, M.D., Director, Division of Adult Mental Health, National Institute of Mental Healrh, l-7-3 Konodai, Ichikawa, Chiba 272, Japan. 0 I989 by Grune & Stratton, Inc. 0010-440X/89/3001-007303.00/0

Comprehensive

Psychiatry,

Vol. 30,

No. 1 (January/February),

1989:

pp 45-52

45

TOORU TAKAHASHI

46

essentials of these phobic disorders consist in a feeling of being in the presence of others and the fact of behaving in public.” The first case report of this type of phobic disorder was published by Casper’ as early as in 1846. This was a case of a 21-year-old male patient with an obsessional fear of blushing (ereuthophobia). Toward the end of the last century, ereuthophobia and allied conditions had attracted the attention of many European psychiatrists and had become one of the topics of neuropsychiatry.3 Some authors considered ereuthophobia as an obsessional disorder, while others interpreted ereuthophobia as a somatic displacement of libido in hysteria.4 This fad, however, did not last long, and the articles on ereuthophobia and allied conditions have almost disappeared from psychiatric literatures of succeeding decades. But the patients with ereuthophobia or allied conditions did not disappear with the fad of thejin du sibcle. Since 1929, a few clinicians reconsidered ereuthophobia and its analogical disorders and revised from a somewhat different viewpoint their clinical conceptions. Several new labels were given by those authors; these include: Kontaktneurosen (Stockert),5 social neurosis (Schilder),6 or social anxiety neurosis (Meyerson).’ More recently, Marks also treated social phobia as a clinical syndrome and detailed its clinical features in his monograph on phobias.* Independently of this Western trend, Japanese psychiatrists have paid particular attention to social phobias, since the publications of series of leading works by Morita on shinkei shitsu (nervous character) in the 1920s and ~OS.~ Morita treated many neurotic patients with obsessional fears, especially those of social contacts named tai-jin kyOfu, formulated his theory of shinkei shitsu, and established a method of psychotherapy for shinkei shitsu patients (the Morita therapy). According to Morita,” shinkei shitsu partly derives from a certain temperament. The person with this temperament falls easily into the state of being preoccupied with trivial dysfunctions of physical or mental activities. Then, he or she becomes entangled with this preoccupation which involves various obsessional fears, insistent hypochondriasis or neurasthenic states. Morita pointed out that shinkei shitsu patients have a certain avidity for predominance over others and a strong adherence to life. He interpreted that phobias of death or of illness represent an adverse effect of such an avid clinging to life, while phobias of social contacts, tai-jin kyOfu, represent an adverse effect of an avid need to predominate over others. He considered tai-jin kyOfu as obsessions of shame originated from this shinkei shitsu temperament and described characteristic manifestations, such as phobia of blushing, giving off improper facial expressions in the presence of others, or looking at others, shaking, perspiring being noticed, etc.” Japanese psychiatrists have elaborated upon and renewed Morita’s concept of tai-jin kyOfu. Their recent studies will be mentioned later in this report. INCIDENCE

OF SOCIAL

PHOBIAS

Since social phobics usually succeed in keeping their disorder from another person’s sight, and since the majority of them are treated in secret by non-physicians in a wide variety of private therapeutic centers, it is difficult to estimate the prevalence of social phobias in the general community. In the author’s series of 179 cases, 163 cases (91%) had been treated in one such private therapeutic center in

SOCIAL PHOBIA SYNDROME

47

IN JAPAN

Tokyo. Of these 163 cases, only 12 cases (7.4%) were treated previously in psychiatric clinics. Uchinuma” found the incidence of social phobias to be 2.5% in psychiatric outpatients who were treated in the psychiatric clinic of Teikyo Medical School in Tokyo from January 1972 to December 1974. In general, social phobias are included in neurotic disorders. Yamashita13 found 21 cases of social phobias in 269 patients with neuroses, or 7.8%, who were treated in the clinic of the Department of Neuropsychiatry of Hokkaido University during 1975. On the other hand, relatively large numbers of social phobics are treated in the psychiatric clinics where the Morita therapy is performed. Ohara14 reported that the incidence of social phobias amounted to 45.5% in neuroses treated in the Kora-kosei Hospital where the Morita therapy has been intensively practiced since 1944. Regarding sex incidence, nearly all descriptions by Japanese authors show a preponderance of men. Both Uchinuma and Ohara, for example, found that the male/female ratio was about 3:2. In the author’s series, it was about 5:4, while Marks reported that the sex incidence of social phobias seen in the Maudsley Hospital in London was 60% women. ONSET OF SOCIAL PHOBIA

Social phobia begins in early adolescence. Figure 1 shows the distribution of ages of onset in the author’s series. A substantial number of patients regarded some trivial events that had occurred during certain social contacts as the precipitants of their disorder. For example, an incidental blushing while being confronted with persons of the opposite sex, or minor stage fright while facing classmates in a class meeting are among the events repeatedly related by patients. On the other hand, gross traumatic events or major changes in the patient’s life situation were rarely reported as a trigger. In the author’s series, only four cases (2.2%) acknowledged that their disorder started with an obviously traumatic event.

60

IO-12

13-15

16-16

Fig 1.

19-21

22-21

25-27

26-

ages

The age of onset (n = 169).

TOORU TAKAHASHI

48

The trigger, though a trivial one, gives rise to a somewhat persisting anxiety, and the subject becomes very sensitive to social situations similar to the circumstances of the initial event. Sooner or later, he or she begins to fear social situations and to fear even the manifestations of various symptoms of social anxiety. SYMPTOMS

SOCIAL

PHOBICS

FEAR

Social phobics are afraid of blushing in the presence of others, of stiffening of their facial expressions, of trembling of the head, hands, feet, or voices, of sweating while facing with others, of their physical deformities being noticed, of emitting body odors, of their line-of-sight becoming uncontrollable, or of uncontrollable flatus in the presence of others. Among these symptoms, blushing in the presence of others is the most common one; 53% of the patients in the author’s series chose this symptom as the principal one among their feared symptoms. But the symptoms they fear often vary over the course of illness. One who starts with ereuthophobia may become dysmorphophobiac, or may begin to fear that he or she cannot help staring at others and making them feel uncomfortable. Those who shifted from one feared symptom to another during the course of illness amounted to 27% in the author’s series. In this respect, it may be worth noting that fear of blushing occurred frequently in the beginning of their illness, while fears of stiffening of one’s facial expressions or of one’s line-of-sight becoming uncontrollable often appeared later. Kasahara” distinguished two groups of fears of social contacts. One includes those fears featured by a component of “being looked at by others.” A fear of blushing in the presence of others represents this group of fears. The other includes those characterized by the predominance-of-the-opponent component, that of “looking at and thus disturbing others.” A fear of one’s line-of-sight becoming uncontrollable is an example of this latter group of fears. Although it may be difficult to classify the fears of many cases into either of these two groups, this classification has certain importance. The patients with fears classified appropriately into the latter group are more seclusive and laden with guilt rather than shyness.” In fact, fear of one’s line-of-sight becoming uncontrollable and thus disturbing others often attains a delusional conviction. The patient cannot help feeling that others are actually disturbed by his or her uncontrollable stare. In the extreme case, the patient complains that, even when keeping his or her eyes shut, a kind of magic power radiates from his or her orbits in all directions and disturbs people nearby. The patient especially feels that the people immediately beside him or her are intensely influenced by and shrink back from his or her stare. Such a delusional type of social phobia occurs as part of so-called shishunki m6s6sh6 (a juvenile paranoia characterized by a persistent conviction of disgusting others by some delusional deformities or dysfunctions of one’s own body),16 waxing and waning together with the more prominent delusional symptoms. Kasahara named these delusional cases “social gravis.” A certain case of body odor may also be labeled gravis type. A patient believes that his or her body so strongly stinks as to make people around him or her sneeze or cough! REACTIONS

TO FEARED SYMPTOMS

Social phobias are more or less disabling because feared symptoms are often provoked by common everyday social contacts and the patients are driven to avoid

SOCIAL PHOBIA SYNDROME

IN JAPAN

49

such contacts. But, since they cannot live in complete seclusion, they attempt to overcome their phobias. They may try to suppress the manifestations of feared symptoms by force of mind. But they soon realize the adverse effect of this volitional suppression. They may then resort to palliative devices to alleviate fears when in a critical situation. The application of face cream to the blushing face may moderate fear of being looked at by others. Some contrive even more astute devices. In a bouncing bus, for example, a patient may begin to pretend to read a newspaper so as to keep his stiffened countenance from the view of other passengers. But, being unable to put up with the oppressed atmosphere in the bus, even by this feigning performance, he or she may get off at a bus stop on the way, making it seem as if he or she had arranged beforehand to alight there. In fact, a substantial number of patients succeed in keeping their phobias in secret to such an extent that they themselves acknowledge that nobody penetrates their intentions behind the facade of palliative or feigning performances. However, few patients are completely satisfied with these palliative devices, because they finally realize that palliatives are palliative and all but ineffective in overcoming their phobias. It is well noted that social phobics seek treatment specially designed for personality change and for improvement of ego-strength; for example, hypnosis, Yoga training, starvation cure, or group therapeutic training. They have a tendency to respond well to the ascetic aspects of such treatments. Often they show a certain stoic will to conquer their phobias. PHOBIA-STIMULATING

SITUATIONS

In spite of the diversity of feared symptoms, as well as of palliative devices to alleviate them, social phobias have a common feature with respect to phobiastimulating situations. One of the most important points in differentiating the social phobia syndrome from other delusional disorders is the fact that, except when in phobia-provoking circumstances, social phobics are sane and bright, just as agoraphobics are free from anxiety while at home. In other words, social phobias are strictly bound up with, as well as circumscribed within, certain social situations. The majority of patients believe that they feel anxious wherever they are in the presence of others. But this is a false belief. In fact, few patients show signs of morbid social anxiety while facing their therapists. On the other hand, there are some who become tense even when surrounded by familiar friends. Moreover, the impressions of “others” vary greatly with circumstances. A fashion model with ereuthophobia related that she felt better on the stage than when facing and talking with people, even friends, in a small group. Based on clinical observations, as well as analyses of the patient’s comments on phobia-provoking circumstances from the communication point of view, Takahashi” pointed out that the critical situation where social phobic symptoms are engendered consists of a certain modulation of the communicational mode of affinity. Social phobics are very sensitive to the slightest modulation of familiarity with other persons and are too ready to conceive ideas of reference. Passengers in a bus may remain utter strangers to the patient. But an incidental exchange of looks often provokes intense dismay in the patient. According to explanations given by patients, they cannot at the time help feeling as if the distance of familiarity with the passengers who they feel are looking at them becomes too close to regulate immediately with appropriate communicational performances.

50

TOORU TAKAHASHI

From the communication point of view, the patient, when in the bus, expresses him- or herself both consciously and unconsciously to the other passengers. On the other hand, he or she makes inference about them through their expressions. The security that patients justifiably feel in consciously expressing themselves to, as well as in making inferences about, other passengers depends upon their adaptability to the actual communicational mode of affinity in that circumstance. An exchange of looks may precipitate, in the mind of sensitive patients, an illusional shift of communicational modes of affinity, from that of affinity with total strangers to that of affinity with more familiar persons. Normal persons may correct this illusional shift almost without awareness, but the patients entangle themselves with this illusion because they are so sensitive to the slightest change of familiarity that they delude themselves into apparent familiarity with a mere exchange of looks. What is more, they soon realize this illusion by inferring that the expressions they gave in accordance with this shifted communicational mode are making improper impressions on other passengers, but they cannot control their expressions to restore the already disrupted communication distance with the other passengers. Social phobics may feel a tension in the atmosphere while taking part in conversation with their colleagues. The critical situation often emerges with no one saying anything. Such a pause in the conversation causes them to impulsively shift from the communicational mode of affinity with familiar people to that with less familiar people. They cannot help feeling as if the people surrounding them turn suddenly distant. From the communication point of view, symptoms the patient fears will be considered as manifestations of the disruption of natural communication, which involves, at the same time, the critical situation. SOCIAL

PHOBIA

SYNDROME

AND DELUSIONAL

DISORDERS

In general, social phobias are classified under the heading of phobic disorders. However, symptoms of sensitiveness to social contacts or ideas of reference are characteristic of social phobias, and the distinction between social phobic ideas of reference and delusions of reference seen in other delusional disorders is of importance in theoretical considerations as well as clinical practice. Social phobic ideas of reference are, firstly, characterized by a feature of self-reference.” Social phobic patients cannot help feeling that others take notice of them. But, at the same time, they acknowledge that these feelings originate within themselves. They even try to resort to palliative devices to conceal manifestations of social anxiety lest they should attract the attention of others. This structural characteristic of self-reference is an important point to distinguish social phobic ideas of reference from other delusions of reference, especially those of paranoid condition in which the paranoid patient feels as if he or she were being controlled, tested, and spied upon by others. Secondly,‘5 social phobic ideas of reference are well circumscribed. Indeed, social phobics become sane and bright when out of the critical situation. Their ideas of reference are strictly bound up with the situations where their feared symptoms are provoked. Thirdly,‘* the content of their ideas of reference usually has hardly a trace of persecution. The patient with social phobias withdraws from and avoids social contacts, but is not a true misanthrope.” Inwardly, he or she seeks contact with

SOCIAL PHOBIA SYNDROME

IN JAPAN

51

others. Usually, they imagine their acquaintances or neighbors as good-natured people and never conceives of them entertaining persecuting plots. The patient is even afraid of hurting them by giving off improper expressions. Ideas of reference seen in the central cluster of social phobias have all these characteristics which permit one to differentiate social phobic ideas of reference from other delusions of reference. But, in a few exceptional cases, especially in the case of social phobia gravis, these characteristics are more or less blurred, and further elaboration based on a diffusion of ideas of reference often flavors the patient’s ideas with persecutional nuances. For example, the whole neighborhood may seem to be gossiping about his or her fierce looks or unpleasant body odor. COURSE AND PROGNOSIS

Accurate accounts of the course and prognosis of social phobias are precluded by the lack of longitudinal studies of a sufficient number of patients over a long period of time. However, although their numbers of patients are small, nearly all studies by Japanese psychiatrists have reported good results. For example, Suzuki” followed up 200 patients with social phobias more than 2 years after discharge from treatment with the Morita therapy and found 88.6% to be recovered or much improved. In the author’s series, followed up for anywhere from 2 months to 8 years after treatment, some 80% (143 cases) of the patients became well, and their symptoms subsided to a point that they were able to conduct themselves as if they were sociable. The complete remission of symptoms for a certain period was often actualized by the contrivance of more astute devices to alleviate fears of social contacts. On the other hand, 20% (36 cases) of the patients were unchanged or worse. In addition, 10.5% (19 cases) of the cases became social phobia gravis during the follow-up period, and two thirds (13 cases) of them fell into this unimproved group. Patients who seek treatment are most commonly in their teens or 20s. Few patients are over 30. Figure 2 shows the distribution of ages of patients treated in the author’s series. The social phobia syndrome is an adolescent neurotic syndrome and is closely related with progressive developments of sociability in adolescence. It has been generally accepted that the maturation of sociability is characterized by the development of innate potentialities of cognition process in ordered sequence. Developmental symptoms, such as the smiling response observed a few months after birth or stranger anxiety at the age of 8 months have to do with the maturation of sociability and have been considered in the context of the development of cognition process based on the innate releasing mechanism. After puberty, adolescents develop a meta-level self-consciousness described as Entdeckung des Zch by Spranger; a self-consciousness with renewed cognitive responses to other persons. Adolescents who become aware of this modulation of self-consciousness show somewhat homologous symptoms to stranger anxieties at the age of 8 months, characterized by excess of timidity and sensitivity similar to social phobias. Therefore, in the consideration of age of onet, the mode of onset, feared symptoms, and the nature of sensitivity to other persons well represented in ideas of reference as well as the prognosis, it seems justifiable to consider the social

52

TOORU TAKAHASHI

”

Fig 2.

The age of treatment

(n = 179).

phobia syndrome as a sensitive neurotic state originated from the developmental modulation of self-consciousness in early adolescence. ACKNOWLEDGMENT I should like to express my thanks to Dr. Ryo Takahashi, Dental University, who encouraged me to write this article.

Professor

of Psychiatry,

Tokyo Medical

and

REFERENCES 1. Janet P: Les Obsessions et La PsychasthCnie, Tome I. Paris, Alcan, 1903, pp 2 16-2 17 2. Casper JL: (traduit par le Dr. Lalanne) Biographie dune idCe fixe. Arch Neurol8: 270-287, 1902 3. Hartenberg P: Les Timides et La Timiditt. Paris, Alcan, 1921, pp 183-216 4. Yamamura M: Seki-men kyofu ni tsuite (1). Tohoku Daigaku Seishin-by&gaku Kybhitsu GyBhB 2: 71-102, 1933 5. Stockert FG: Klinik und atiologie der kontaktneurosen. Klin Wochenschr 8: 76-79, 1929 6. Schilder P: The social neurosis. Psychoanal Rev 25: 1- 19, 1938 7. Meyerson A: The social anxiety neurosis; its possible relationship to schizophrenia. Am J Psychiatry 101: 149-156, 1945 8. Marks I: Fears and Phobias. London, Heinemann. 1969, pp 113, 152-l 57 9. Kora T (ed): Morita Masatake Zensht?, vol 1 & vol 2. Tokyo, Hakuyousha, 1974 IO. Morita M: Shinkei shitsu no gainen, 1932, in Kora T (ed): Morita Masatake Zenshu, ~012. Tokyo, Hakuyousha, 1974 pp 45-57 11. Morita M: Seki-men kyofu (matawa tai-jin kyofu) to sono rybhd, 1932, in Kora T (ed): Morita Masatake Zenshu, ~012. Tokyo, Hakuyousha, 1974, pp 164-174 12. Uchinuma Y: Tai-jin kyofu no ningen gaku. Tokyo, Kobundo, 1977, pp 4, 158-190 13. Yamashita I: Tai-jin kyofu. Tokyo, Kanehara, 1977, p 72 14. Ohara K, Aizawa S, Iwai A: Morita ryoho. Tokyo, Bunk&lo, 1968, pp 86-87 15. Kasahara Y, Fujinawa A, Sekiguchi H, et al: Fear of Eye-to-Eye Confrontation and Fear of Emitting Bad Odors (in Japanese). Tokyo, Igaku-shoin, 1972, pp 5,22 16. Murakami Y: Shishunki M&B-she, in Takahashi T (ed): Tai-jin kydfu-she. Tokyo, Kanehara, 1985, pp 43-50 17. Takahashi T: Tai-jin kyofu. Tokyo, Igaku-shoin, 1976, pp 55-65 18. Miyamoto T, Onizawa C: Tai-jin kyofu to Seishin-bunretsu-by& in Takahashi T (ed): Tai-jin kyofu-shb. Tokyo, Kanehara, 1985, pp 51-60 19. Takahashi T: A social club spontaneously formed by ex-patients who had suffered from anthropophobia (tai-jin kybfu). J Sot Psychiatry 21: 137-144, 1975 20. Suzuki T: Tai-jin kyofu no keika yogo, in Takahashi T (cd): Tai-jin kyofu-she. Tokyo, Kanehara, 1985, pp 183-197